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A nurse is caring for a client who is 2 weeks postpartum following a cesarean
birth. Which of the following clinical fndings should the nurse identify as an
indication of postpartum infection?
a. Unilateral breast pain
b. Persistent abdominal striae
c. Lochia alba
d. WBC count 12,000/mm3 - ✔✔a. Unilateral breast pain
A nurse is assessing client who has preeclampsia during a prenatal visit. Which
of the following findings should the nurse report to the provider?
a. Blood glucose 110 mg/dL
b. Deep tendon reRexes of 2+
c. Urine protein of 3+
d. Hemoglobin 13 g/dL - ✔✔c. Urine protein of 3+
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,A nurse is providing teaching about the expected effects of magnesium sulfate
to a client who is at 28 weeks of gestation and has preeclampsia. Which of the
following responses by the nurse is appropriate?
a. "This medication improves tissue perfusion."
b. "This medication increases cardiac output."
c. "This medication stabilizes the fetal heart rate."
d. "This medication prevents seizures." - ✔✔d. "This medication prevents
seizures."
A nurse is teaching a prenatal class regarding false labor. Which of the following
information should the nurse include?
a. "You will have dilation and effacement of the cervix."
b. "Your contractions will become temporarily regular."
c. "You will have bloody show."
d. "Your contractions will become more intense when walking." - ✔✔b. "Your
contractions will become temporarily regular."
A nurse manager is revising a maternal unit policy to ensure proper
identification of newborns. Which of the following should the nurse include in
the policy?
a. Check the newborn's identification using the crib card.
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,b. Replace the infant's identification band after his name has been recorded.
c. Require visitors to wear an identification band.
d. Obtain an imprint of the infant's feet prior to taking him to the nursery. -
✔✔d. Obtain an imprint of the infant's feet prior to taking him to the nursery.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse
notes a steady trickle of vaginal bleeding that does not stop with fundal
massage. Which of the following actions should the nurse take?
a. Apply an ice pack to the incision site.
b. Replace the surgical dressing. c. Administer 500 mL lactated Ringer's IV bolus.
d. Evaluate urinary output. - ✔✔d. Evaluate urinary output.
. A nurse is providing discharge instructions to a client who is postpartum and
has engorged breasts. Which of the following nonpharmacological comfort
measures should the nurse include in the teaching?
a. Wear nipple shields during the feeding.
b. Use a breast binder for 2 days. c. Use plastic-lined breast pads. d. Apply
cabbage leaves a^er feedings - ✔✔d. Apply cabbage leaves a^er feedings
A nurse is calculating estimated date of birth using Naegele's rule for a client
who is pregnant and whose last menstrual cycle started June 21. Which of the
following is the estimated delivery in the next year?
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, a. March 14
b. March 21
c. March 28
d. April 4 - ✔✔c. March 28
A nurse is caring for a client immediately following the delivery of a stillborn
fetus. Which of the following actions should the nurse take?
a. Inform the client that the law requires her to name the fetus.
b. Limit the amount of time the fetus is in the client's room.
c. Instruct the client that an autopsy should be performed within 24 hr.
d. prepare the client for what to expect the fetus to look like - ✔✔d. prepare the
client for what to expect the fetus to look like
A nurse is observing an adolescent client who is offering her newborn a bottle
while he is lying in the bassinet. When the nurse offers to pick the newborn up
and place him in the client's arms, the mother states, "No, the baby is too tired
to be held." Which of the following actions should the nurse take?
a. Demonstrate how to hold the newborn and allow client to practice.
b. Persuade the client to breasfeed the newborn to promote bonding.
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